Final Report of the Ockenden Review (March 2022).
This is the independent review into maternity care at the Shrewsbury & Telford Hospital NHS Trust, led by Donna Ockenden, which examined 1,486 family cases of maternal, fetal, neonatal death and injury over the period 2000–2019. The report presents findings of systemic failures in care, investigation, governance, and learning, showing that at least 201 babies and nine mothers may have survived if care had been better. It issues 60+ Local Actions for Learning for that Trust and 15 Immediate & Essential Actions for all maternity services in England, covering safe staffing, escalation and accountability, stronger investigation processes, culture change, leadership, training and family-inclusive practices. This is a pivotal resource for all maternity care professionals and health system leaders seeking evidence-based, urgent reforms to improve safety and accountability across maternity services.